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PubMed1990

Admission source to the medical intensive care unit predicts hospital death independent of APACHE II score.

This study was conducted to determine if the source of admission to the medical intensive care unit (MICU) is associated with hospital death independent of the Acute Physiology and Chronic Health Evaluation (APACHE) II score. We calculated APACHE II scores and predicted risks of hospital death for 235 patients who were admitted to the MICU. The predicted death rate was the same as the actual rate for patients who were admitted directly from the emergency department (25% vs 22%), but was less than the actual rate for patients who were transferred from hospital floors (38% vs 55%), the medical intermediate care unit (32% vs 59%), and other hospitals (21% vs 36%). Logistic regression analysis confirmed an independent association between the MICU admission source and risk of death. Our findings suggest that APACHE II does not measure illness severity accurately in all patients who are admitted to intensive care units. If our results are generalizable, using APACHE II to compare intensive care outcomes among hospitals could lead to wrong conclusions about quality of care. Improving predictions of hospital death rates among patients who are in MICUs may require the inclusion of new types of information in the classification system.

Admitting Department, Hospital↗
PubMed1989

[Severity evaluation system: APACHE II, SAPS. National experience in a unit of medical intensive therapy].

We evaluated 2 new prognostic indices, APACHE II and SAPS, in 533 consecutive patients admitted to a general hospital clinical care unit. Mortality was 19.5% (13.1% in the ICU). Among non-survivors 80% had a greater than = 20 APACHE II score and 77% a greater than = 13 SAPS score. Only 2% of patients with APACHE score less than 10 or SAPS less than 7 died. A good correlation with previously used indices (APACHE I and TISS) was 0.6. Utilization of these prognostic indices allows comparison of reports from different centers, evaluation of early and long term prognosis and a help in making cost-benefit decisions.

Chile↗
PubMed1989

[Use of the APACHE II scoring method for registering patients receiving intensive care at a central hospital].

The APACHE II scoring method was employed prospectively for registration of patients in intensive care in a central hospital. Scoring was performed in a total of 390 patients. Seventy-three patients (20.2%) of the patients died in hospital. A significant difference in the APACHE II score was found in the surviving patients (9 points) as compared with those who died (19 points). A significant linear connection was found between the frequency of death observed and the estimated risk of death in hospital. The APACHE II score could not be correlated to the number of bed-days in the intensive care unit but to the resources employed measured as the number of therapeutic procedures carried out. The APACHE II scoring method was found to be employable in the prognosis for survival as a control of quality, as a tool for description of the degree of severity of illness and as an indirect measurement of the resources required.

Adult↗
PubMedDate not supplied

[Predictive value of the APACHE and TISS indices on the postoperative morbidity in vascular surgery].

The predictive value of age, weight, APACHE score (preoperative and 48 hours after surgery), and TISS index (24 and 48 hours after surgery) on morbidity has been studied on a group of 101 patients undergoing diverse vascular surgical procedures, with a complication rate of 47%. The 48 hour after surgery TISS alone, could correctly predict the postoperative course in 78% of the cases. This index, combined with the preoperative APACHE score, adequately predicted the course in 79% of the patients. When the 48 hour postoperative APACHE score was added to these two, the prediction was correct in 80%. A discriminant function including both APACHE scores, the 24 hour postoperative TISS, and age allows a proper classification in 81% of the cases. When the same criteria were used in another group of 56 patients--with 38% of postoperative complications--the results obtained showed no statistically significant difference. We conclude that both, the bayesian criterium, and the discriminant function can successfully be used for the prediction of the postoperative morbidity in vascular surgery.

Adult↗
PubMed1993

Predicting survival in AIDS patients with respiratory failure. Application of the APACHE II scoring system.

This article describes the APACHE II classification system as a measure of severity of illness applied to AIDS patients with respiratory insufficiency. Among 82 patients, observed mortality in patients with high APACHE II scores (greater than 30) and those with low scores (less than 18) was significantly higher than predicted. There was variable correlation between predicted and observed mortality in the other APACHE II score ranges. The usefulness of the APACHE II scoring system is reviewed as limited and inaccurate in predicting survival rates in AIDS patients with respiratory failure.

Adult↗
PubMed1996

Prediction of the risk of death by APACHE II scoring in critically ill trauma patients without head injury.

The ability of the Acute Physiology And Chronic Health Evaluation (APACHE) II scoring system to predict outcome in 199 critically ill patients with trauma but without head injury was assessed prospectively over an 8-month period. Some 178 patients (89.4 per cent) underwent operation and 50 (25.1 per cent) died, 44 after operation and six without undergoing surgery. The mean(s.d.) APACHE II score was 8.0(5.2) for survivors and 14.5(5.5) for non-survivors (P < 0.001). In patients who underwent surgery the mean(s.d.) scores were 7.7(4.6) and 13.4(5.5) (P < 0.001) and for those managed without operation 11.1(7.2) and 14.7(6.3) (P = 0.31) in survivors and non-survivors respectively. The predicted risk of death and observed mortality rate were 5.1 and 25.1 per cent respectively for the entire group, 5 and 25 per cent for patients undergoing surgery, and 7 and 29 per cent for those not operated on. Although the APACHE II system correctly identified all survivors (specificity 100 per cent), it failed to predict death in any patient (sensitivity 0 per cent). The results suggest that this objective prognostic scoring system is not applicable to the patient with trauma who does not have concurrent head injury.

APACHE↗
PubMed1994

Comparison of serum phospholipase A2, polymorphonuclear granulocyte elastase, C-reactive protein and serum amyloid A with the APACHE II score in the prognosis of multiple injured patients.

This prospective study of 35 multitraumatized intensive care unit patients requiring mechanical ventilation examined the relative utility of four biochemical parameters with a physiological scoring system for predicting lethal outcome. Levels of serum phospholipase A2 (PLA2), serum amyloid A (SAA), polymorphonuclear granulocyte elastase (PMN elastase), and C-reactive protein (CRP) were determined at short intervals during the patient's hospitalization. The first specimen was obtained at the time of admission, and subsequent specimens were drawn at 8 h intervals for the first 48 h and then twice daily until death or convalescence. Calculations of the APACHE II score used the most deranged variables during the first 24 h of admission to assess patient outcome. Additional calculations of the APACHE II score at the time of each blood draw served as an indicator of patient status. The results indicate that during the first 24 h after admission none of the four examined biochemical parameters gives reliable information about the outcome. The APACHE II score provided the earliest indicator of patient outcome (83% sensitivity, 65% specificity). PMN elastase provided useful information first at 32 h (83% sensitivity, 45% specificity) and better at 132 h (86% sensitivity, 86% specificity). CRP was of intermediate use in predicting outcome initially at 72 h (83% sensitivity, 50% specificity) and later at 132 h (86% sensitivity, 93% specificity). PLA2 and SAA were not useful as early indicators of lethal outcome.

APACHE↗
PubMed1994

[Prognostic scores in peritonitis: the Mannheim Peritonitis Index or APACHE II?].

Scoring systems are mandatory to quantify the severity of abdominal sepsis on the basis of objective criteria. The Mannheim Peritonitis Index (MPI) is a disease-specific score based on easy to handle clinical parameters. APACHE II is a large-scale general scoring system with acute physiological and chronic health parameters. To evaluate the prognostic value of both systems 108 patients with severe abdominal infection managed by open treatment entered a prospective study. 32 patients (29.6%) died, 23 of them due to sepsis and 9 from other causes. Both MPI and APACHE II scores correlated closely with mortality, with three and two significantly different classes, respectively. Statistical validation showed a sensitivity of 93% and a specificity of 16% for MPI, and 89% and 25% for the APACHE II. ROC curves were nearly parallel for both scores. In conclusion there was no significant difference in prognostic value between the scoring systems.

APACHE↗
PubMed1996

Outcome prediction for patients with cirrhosis of the liver in a medical ICU: a comparison of the APACHE scores and liver-specific scoringsystems.

OBJECTIVE: To find the most adequate prognostic scoring system for predicting ICU-outcome in patients with decompensated liver cirrhosis in a medical intensive care unit (ICU). DESIGN: Retrospective analysis of patients' records over a 10-year period. SETTING: A medical ICU at the university medical center of Vienna. PATIENTS AND PARTICIPANTS: 94% (n = 198) of all patients with cirrhosis admitted to our medical ICU throughout the 10-year study period. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: From data obtained at admission and at 48 h after admission, scores were calculated using the following scoring systems: Acute Physiology and Chronic Health Evaluation (APACHE) II and III, Scale for Composite Clinical and Laboratory Index Scoring (CCLI), Mayo Risk Score, and Child's Classification. Statistical analysis for the prognostic variables was performed using the chi-square test, t-test, Youden index, and area under a receiver operating characteristic (ROC) curve. APACHE III was found to be the most reliable outcome predictor at admission and after 48 h for patients with decompensated liver cirrhosis (AUC = 0.75 and 0.8, respectively). CONCLUSIONS: To predict the outcome for patients with decompensated cirrhosis of the liver admitted to a medical ICU liver failure alone is not decisive. Liver-specific scoring systems (Mayo Risk Score, CCLI) are adequate, but the APACHE II and III proved to be more powerful, because they include additional physiologic parameters and therefore also take into account additional complications associated with this liver disorder.

APACHE↗
PubMed1996

Application of the APACHE III prognostic system in Brazilian intensive care units: a prospective multicenter study.

OBJECTIVE: To compare patients and their outcomes at ten Brazilian intensive care units (ICUs) with those reported from the United States. DESIGN: Prospective multicenter inception cohort study. SETTING: Ten Brazilian adult medical-surgical ICUs. PATIENTS: 1734 consecutive adult ICU admissions. MEASUREMENTS AND RESULTS: We used demographic, clinical and physiologic information and the APACHE III prognostic system to predict risk of hospital death for 1734 ICU admissions. We then divided the observed by the predicted hospital death rate to calculate standardized mortality ratios (SMRs) for patient groups and each ICU. Hospital mortality for Brazilian patients (34%) was double that found in the United States (17%, p < 0.01). Discrimination of survivors from non-survivors using APACHE III was good (area under a receiver operating characteristic curve = 0.82), but the predicted risk of death was significantly (p < 0.0001) lower than observed outcome (SMR = 1.67). Three of the ten Brazilian ICUs, however, had SMRs of 1.01 to 1.1 and no significant difference between observed and predicted outcomes; the remaining seven ICUs had significantly higher SMRs, ranging from 1.50 to 2.30. CONCLUSION: The APACHE III prognostic system was a good discriminator of hospital mortality for ICU admissions at 10 Brazilian ICUs. There was substantial and significant variation, however, in SMRs among the Brazilian ICUs, which suggests that further evaluations of international differences in intensive care using a common risk assessment system should be performed and factors associated with variations in risk-adjusted mortality scrutinized.

APACHE↗
PubMed2000

[The SOFA score in evaluating septic illnesses. Correlations with the MOD and APACHE II score].

The SOFA score, a new system for patients with sepsis-related diseases, was introduced in 1994 by the "Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine." The purpose of this study was to compare the new SOFA score with the APACHE II and MOD scores. The data on 874 patients from a surgical intensive care unit in an university hospital were analyzed using commercially available software (SPSS for Windows, Version 7.5.2 and MS Excel '97). To compare the different scores, receiver-operating characteristics (ROC)--analyses were applied. The study demonstrated clear correlation between an elevated SOFA score and the mortality of the patients during their ICU stay (score 0-->mortality 0%, 1-->3.6%, 2-->22.5%, 3-->86.7%, respectively r = 0.445; P = 0.01). The ROC analyses of the APACHE II, the MOD and the SOFA scores were comparable (area under the curve: APACHE II 0.73, MOD 0.77, SOFA 0.71). In conclusion, the SOFA score is reliable and might be useful in the daily routine of an intensive care unit.

APACHE↗
PubMed2002

Customized prediction models based on APACHE II and SAPS II scores in patients with prolonged length of stay in the ICU.

OBJECTIVE: To study customized APACHE II and SAPS II models in predicting hospital death in patients with a prolonged length of stay in the ICU. DESIGN: Prospectively collected database. SETTING: Thirteen ICUs with 5-10 beds in Finnish secondary referral hospitals. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The database was collected between 1994 and 1999 and included 23,953 ICU admissions. In order to customize the original APACHE II and SAPS II models and to validate the models, the database was randomly divided into customization data ( n=12,064) and into validation data ( n=11,889). Logistic regression analysis was used for customization. As the length of the ICU stay was prolonged, the calibration and discrimination of both customized models worsened gradually in the validation data. Patients whose ICU stay lasted 7 days or longer (1,312 patients) consumed more than one half of all ICU days and TISS-points. Among these patients, goodness-of-fit statistics was 221.5 and 306.3 ( P<0.0001 for both) and the areas under ROC curve 0.65 and 0.62 for the customized APACHE and SAPS models, respectively. The models underestimated the risk of death in the low range and overestimated it in the high range of predicted mortality. On the other hand, both models discriminated well between survivors and non-survivors if the ICU stay was 2 days or less. CONCLUSIONS: Despite customization, the predictive models may not support clinical decision-making in those patients who require a high share of resources. More relevant instruments are needed for the prediction of outcome of patient groups who consume the major part of ICU resources.

APACHE↗
PubMed1998

The Apache III prognostic system: customized mortality predictions for Spanish ICU patients.

OBJECTIVE: To customize the Acute Physiology and Chronic Health Evaluation (APACHE) III mortality equation for Spanish admissions to the intensive care unit (ICU) and evaluate its discrimination and calibration. DESIGN: Prospective multicenter inception cohort study. SETTING: 86 ICUs located in all regions of Spain. PATIENTS: 10,929 adult patients selected by a systematic sampling method. All types of critical care patients were included, including coronary bypass patients, but excluding those with burn injury, those admitted for pacemaker implants, patients under 16 years of age, and patients with length of ICU stay < 6 h. MEASUREMENTS AND RESULTS: Data collection in the first 24 h after patient admission included: APACHE III score, treatment location prior to ICU admission, and main ICU admission diagnosis. Using these variables, a model for predicting hospital mortality was constructed, adapted to Spain, and its discriminating ability was assessed by the area below the ROC curve, which was 0.83. The model was validated using the jacknife method and the area below the receiver operating characteristic (ROC) curve for the cross-validated predictions was 0.82. The percentage of patients correctly classified at 0.50 risk of death was 82.3%. Model calibration was evaluated by analysis of the agreement between the observed and cross-validated predicted mortality using the Hosmer-Lemeshow test, which gave a value of (H) 12.27, with no statistical significance, i.e., good calibration. CONCLUSIONS: We have customized the APACHE III mortality prediction system for the Spanish population. This adapted model has demonstrated the requisite validation, calibration, and discrimination for its use among Spanish critical care patients.

APACHE↗
PubMed1998

APACHE II score: a useful tool for risk assessment and an aid to decision-making in emergency operation for bleeding gastric ulcer.

BACKGROUND: Operating for bleeding gastric ulcer remains controversial. Gastric resection bears a higher surgical risk while limited operation may result in more postoperative hemorrhage. There has been little discussion of effective risk assessment of patients. The aim of this study is to define surgical risk by using the APACHE II scoring system, and to determine optimal management. STUDY DESIGN: Records from October 1990 to December 1996 were retrospectively reviewed for patients (n=101) with bleeding gastric ulcer who had undergone emergency operation after failed endoscopic therapy. Mortality rates were examined according to different APACHE II scores, and the surgical risk was defined. From January 1997 to December 1997, 35 consecutive patients were enrolled for prospective study. Partial gastric resection (PGR) was performed for patients with huge ulcers (>2 cm) and for low-risk patients with ulcers at the antrum or angularis, while limited operation (oversewing or excision of bleeding ulcer) was reserved for others. The results were compared with the retrospective study. RESULTS: In the retrospective study, the mortality rates for the group with a score < 15 and > or = 15 were 5% (3 of 63) and 58% (22 of 38), respectively (p < 0.05). In the group with a score < 15, PGR was performed on 27 patients, and one died. For those patients with a score > or = 15, PGR carried a lower mortality than limited operation, although this was not statistically significant (47% vs 65%). Limited operation resulted in an overall rate of 22% postoperative hemorrhage and 12% reoperation rate, in which all patients with a score > or = 15 died. In the prospective study, the mortality rates in those scoring <15 and > or = 15 were 6% and 50%, respectively. This is not significantly different than the retrospective study. However, the rate of postoperative hemorrhage was diminished (5%). CONCLUSIONS: APACHE II score is a useful tool for assessing risk in patients with bleeding gastric ulcer. The mortality is minimal in those with a score <15, and PGR can be performed with low risk. Although high-risk patients have dreadful outcomes, limited operation cannot improve them if postoperative hemorrhage occurs. Decision making in emergency operation for such patients should be based on the ulcer conditions and the patient's hemodynamic status.

APACHE↗
PubMed1998

APACHE II, data accuracy and outcome prediction.

From review of 122 intensive care charts, Acute Physiology and Chronic Health Evaluation (APACHE) II points were determined for eight physiological values. Using a strict interpretation of APACHE II criteria, an average of 20.6% of these points were higher and 6.7% lower than the points entered originally into an intensive care database. The resulting 1.73 points mean increase in APACHE II score increased predicted mortality from 24.8% to 27.8% and decreased the mortality ratio (observed hospital deaths devided by predicted deaths) from 1.52 (95% confidence interval: 1.11-2.03) to 1.35 (95% confidence interval: 0.99-1.81). There were few errors entering the data recorded on the audit form into the intensive care unit database with an optical mark reader and keyboard. Inaccuracy and inconsistency in data collection must be excluded before differences in mortality ratios are ascribed to intensive care unit performance.

APACHE↗
PubMed2002

Clinical relevance of intracellular cytokines IL-6 and IL-12 in acute pancreatitis, and correlation with APACHE III score.

Pro-inflammatory cytokines are involved in the pathogenesis of acute pancreatitis (AP). Here, we measure and correlate clinically the percentages of peripheral blood mononuclear cells (PBMC) that contain interleukin (IL)-6 and IL-12 and compare these with acute physiology and chronic health evaluation (APACHE III) scores in 30 patients with AP. Severity of AP is determined according to the Atlanta criteria. Patients with severe AP (n = 15) had significantly higher IL-6 values compared to those with mild AP (n = 15). IL-12 levels correlated well with aetiological factors (alcohol and biliary pathology) in patients with AP. Correlation was seen between IL-6 value and APACHE score in severe AP. A score of 30 points was used as the cut off between mild (<30) and severe (>30) cases, with a sensitivity of 80% and specificity of 100%. Cut off percentages for IL-6- and IL-12-positive PBMCs were >25% (positive predictive value [PPV]: 100%) and >9% (PPV: 70%), respectively. Based on these results, it would seem logical to use both APACHE III score and IL-6 percentage to assess severity in patients with AP.

APACHE↗
PubMed1996

Plasma proinflammatory cytokine concentrations, Acute Physiology and Chronic Health Evaluation (APACHE) III scores and survival in patients in an intensive care unit.

OBJECTIVE: To more clearly define the relationships between plasma proinflammatory cytokine concentrations, physiologic disturbance, and survival in severely ill patients. DESIGN: Prospective, longitudinal, cohort analytic study. SETTING: Teaching hospital intensive care unit (ICU). PATIENTS: Two hundred fifty-one consecutive nonselected patients admitted to the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Daily Acute Physiology and Chronic Health Evaluation (APACHE) III scores were calculated from clinical and laboratory data. In concurrent blood samples, plasma concentrations were measured of four proinflammatory cytokines (tumor necrosis factor-[TNF] alpha, interleukin [IL]-1 beta, IL-6, and IL-8), all of which are believed to be of central importance in host proinflammatory and immune responses. Plasma TNF concentrations were increased in 42 patients, plasma IL-1 beta in 15 patients, IL-6 in 194 patients, and IL-8 in 52 patients at presentation. Although admission plasma IL-1 beta, IL-6, and IL-8 concentrations were higher in patients who died in the ICU compared with survivors (n = 33; p < .02, p < .01, p < .02, respectively), only admission plasma IL-8 concentrations were higher in patients with a fatal outcome if all in-hospital deaths were considered (n = 53; p = .05). APACHE III score was the best predictor of mortality (odds ratio 11.41; p = .003). Detection, but not the absolute level, of TNF bioactivity in plasma was a weak independent predictor of death (odds ratio 3.17; p = .02). There was no relationship between bacteremia or presence of the systemic inflammatory response syndrome and plasma cytokine concentrations. Nineteen patients were in the ICU for > or = 10 days, and of these 19 patients, 16 patients had prolonged increases of plasma cytokines. Two patients with persistently increased plasma TNF concentrations died. Otherwise, persistently increased plasma cytokine concentrations had a variable relation to daily APACHE scores and to mortality. CONCLUSIONS: Plasma cytokine concentrations fluctuate in serious illness and have a poor correlation with derangement of whole body physiology in seriously ill patients. Only the presence of bioactive TNF in plasma was an independent predictor of mortality. Daily measurement of plasma proinflammatory cytokine concentrations is unlikely to have clinical application in the ICU setting, except possibly in specific subgroups of patients.

APACHE↗
PubMedDate not supplied

Effect of anti-OprF-OprI immunoglobulin on APACHE II score in a porcine two-hit model of hemorrhagic shock/resuscitation and pseudomonas aeruginosa sepsis.

BACKGROUND: Up to now, randomized clinical trials of treatment of bacterial sepsis with immunoglobulins show conflicting results. This paper investigates the effect of prophylactic immunization with anti-OprF-OprI antiserum on the APACHE II score in a clinically relevant two-hit model of hemorrhagic shock/resuscitation followed by Pseudomonas aeruginosa sepsis in pigs. METHODS: Twenty-three German Landrace-Hybrid pigs underwent chronic implantation of vascular catheters (internal and external jugular vein, carotic and pulmonary artery), hemorrhagic shock (mean blood loss 40% of estimated blood volume) for 45 min, followed by resuscitation with crystalloid, colloid, and shed blood. Randomization was to a control group (no immunization, n=6), an F-I group (50 mg/kg i.p. anti-OprF-OprI immunoglobulin, n=6), an S group (50 mg/kg i.p. unspecific porcine immunoglobulins, n=6), and a PS group (50 mg/kg i.p. immunoglobulin against the antigens of heat-killed P. aeruginosa, n=5). After at least 18 h for recovery from anesthesia, the pigs underwent a continuous intravenous infusion of P. aeruginosa for 48 h. Thereafter, the animals were monitored for another 48 h and then dissected. RESULTS: The APACHE II score significantly increased from baseline value in all groups during bacterial challenge. However, there were no between-group differences in APACHE II score. In contrast, pigs of the F-I and PS groups showed significant lower lung concentrations of P. aeruginosa (p<0.05 vs. control group) at autopsy. CONCLUSION: These experimental data suggest that under comparable clinical conditions, a prophylactic immunization with anti-OprF-OprI immunoglobulin would not have an overall benefit to patients with P. aeruginosa sepsis.

APACHE↗